Bariatric Surgery Program

Transcription

1 Bariatric Surgery Program Hawai i s first program with a director who has walked the path you re on

2 Your bariatric surgery Handbook Your Role 3 Morbid Obesity and its Medical Impact 3 Body Mass Index Chart 4 Why Consider Major Surgery? 7 Setting Realistic Expectations 8 Promotion of Weight Loss With Bariatric Surgery 8 Explore the Benefits and Risks of Gastric Bypass Surgery 9 The Normal Digestive Process 10 Malabsorptive Procedures 10 Restrictive Procedures 11 Combination Procedures 12 Roux-en-Y Gastric Bypass 12 Bariatric Surgery An Overview of Procedures 14 Expected Weight Loss After Gastric Bypass 15 Diet 16 Nutritional Expectations 16 General Recommendations 18 Foods That May Be Difficult To Tolerate 18 Our Bariatric Surgery Program Team 19 Your role You play a critical role in the long-term success of your surgery. You will need to: Commit to improving your health. Discuss your health history with your surgeon. Discuss any questions or concerns you have and learn all you can about the surgery before making a decision. Follow all instructions on preparing for your surgery. Commit to following all instructions described in the bariatric surgery guide on nutrition, activity and other care after surgery (given to you by your surgeon before surgery). Both the bariatric team and you must commit to honesty, responsibility and cooperation in order to increase your succes ate. Morbid obesity and its Medical impact A clear understanding of morbid obesity is very important, because this is what is used to guide physicians in selection of therapy for people who are overweight. A person is considered clinically severely obese (morbidly obese) when he or she is so heavy that the fat tissue load creates (or will create) other medical problems. Morbid obesity is a chronic condition that is very difficult to treat. Roughly, individuals are considered morbidly obese if their weight is more than 100 pounds in excess of the ideal body weight. A more exact (and more widely accepted) way to define morbid obesity is to use the body mass index (BMI). I talk to them about what they will be going through so they don t feel alone. They call me at any time just to talk. Christi Keliipio, R.N., M.S.N., FACHE Bariatric Surgery Program Director; former bariatric surgery patient The BMI is calculated as follows: BMI=weight (kg)/height (m 2 ) Morbidly obese people have higher rates of medical problems, translating into greater need for weight loss and the rationale for more extreme measures (such as bariatric surgery) to control the weight. The medical complications of obesity may occur in moderately obese people but the frequency of these associated problems (such as heart disease, high blood pressure, diabetes, premature death, etc.), increases 2 3

3 bmi as a Function of HeigHt and WeigHt in Feet, inches and pounds bmi as a Function of HeigHt and WeigHt in Feet, inches and pounds NormaL overweight obese Bmi extreme obesity Bmi HeigHt inches BoDy WeigHt (PouNDS) HeigHt inches BoDy WeigHt (PouNDS) Source: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. 4 5

4 It will change your life. It is one of the hardest, and the best thing you will ever do. Clesson Werner Pali Momi bariatric surgery patient dramatically as weight increases. For example, very obese men between the ages of 25 and 35 are 12 times more likely to die prematurely compared to normal weight men of the same age. Medical conditions that are commonly caused or made worse by obesity: Respiratory conditions obstructive sleep apnea, obesity hypoventilation syndrome, asthma/reactive airway disease Heart conditions high blood pressure, heart failure caused by pulmonary hypertension, higher risk of coronary artery disease (atherosclerosis) Abdominal conditions gallbladder disease, GERD (recurrent heartburn), recurrent ventral hernias, fatty liver Endocrine conditions diabetes, hirsutism, hyperlipidemia, hypercholesterolemia Urinary and reproductive conditions frequent urinary tract infections (uti s), stress urinary incontinence, menstrual irregularity or infertility Musculoskeletal conditions degeneration of knees and hips, disc herniation, chronic non-surgical low back pain Skin conditions multiple disorders, most related to diabetes and yeast infections between skin folds Cancer risk breast, uterine, prostate, renal, colon, pancreatic, gastric, gallbladder and endometrium A BMI 40 and above indicates that a person is morbidly obese and therefore a candidate for bariatric surgery. Bariatric surgery may also be an option for people with a BMI between 35 and 40 who suffer from life-threatening cardiopulmonary problems or diabetes. However, as in other treatments for obesity, successful results depend mainly on motivation and behavior. For nearly all people with morbid obesity, bariatric surgery is the standard of care. When other medically supervised treatments have failed, bariatric surgery offers the best option of long-term weight control. One of the most popular and successful surgical approaches is the Roux-en-Y gastric bypass. Gastric bypass surgery is a time-tested operation. It has been endorsed by a 1991 consensus panel convened by the National Institute of Health (NIH), as WHY consider Major surgery? Nearly 80% of obese patients have one or more of the following conditions: Diabetes Dyslipidemia Gallbladder disease Coronary Artery Disease/ Hypertension Osteoarthritis the only effective means of inducing significant long-term weight loss for the vast majority of patients with morbid obesity. Bariatric surgery has proven effective in treating these conditions. In one study of 104 patients at 1 year post-operation, 90.8% of patient conditions were improved or completely eliminated. See graph below. ELIMINATE IMPROvE NO CHANGE WORSE Osteoarthritis (64) Hypercholesterimia (62) GERD (58) Hypertension (57) Sleep Apnea (44) Hypertriglyceridemia (43) Peripheral Edema (31) Stress Incontinence (18) Asthma (18) Diabetes (18) Schauer, et al, AnnSurg 2000 Oct:232(4): % 20% 40% 60% 80% 100% 6 7

5 Kenneth Jones, Surgery 5/13/11, lost over 100 pounds before setting realistic expectations after The goal of surgery is to help lose over half of your excess weight. This can reduce or prevent health problems. Keep in mind that: It s not cosmetic surgery. Other medically managed weight loss methods must be tried first and documented. Surgery is only an option if other methods have not been successful. Surgery is meant to be permanent. You will need to make lifestyle changes for the rest of your life. You must commit to making good food choices and being more active after surgery. Otherwise, you will not maximize your weight loss. You will not reach a healthy weight right away. Most of the weight is lost steadily over the first year and a half after surgery. The surgery is a tool, which will help you lose weight and by being diligent with exercise and attending support groups and workshops, your chances of losing more weight will dramatically increase. promotion of WeigHt loss WitH bariatric surgery Surgeons use techniques that produce weight loss primarily by limiting how much the stomach can hold. These restrictive procedures are often combined with modified gastric bypass procedures that somewhat limit calorie and nutrient absorption. two WaYs surgical procedures promote WeigHt loss By decreasing food intake (restriction), gastric banding, gastric bypass and vertical-banded gastroplasty are surgeries that limit the amount of food the stomach can hold by closing off or removing parts of the stomach. These operations also delay emptying of the stomach (gastric pouch). Note: The majority of patients report feeling full and satisfied after a small amount of food, and not feeling excessively hungry most of the time. If much more than a quarter cup of food is eaten at once, the patient will feel uncomfortable and may vomit. In the gastric bypass procedure, a surgeon makes a direct connection from the stomach to a lower segment of the small intestine, thus bypassing the duodenum and some of the jejunum. This procedure causes food to be poorly digested and absorbed (malnutrition). Note: vitamin and mineral supplements and a high protein intake will be a lifetime commitment to prevent the problem of nutritional deficiencies. Although results of the operations using these procedures are more predictable and manageable, side effects persist for some patients. explore the benefits and risks of gastric bypass surgery benefits Most patients lose weight rapidly and continue to do so until months after the procedure. Significant sustained weight loss. Although many patients regain some of their weight after 24 months, few regain it all. Bariatric surgery improves or eliminates most obesity related conditions such as high blood pressure, high cholesterol, sleep apnea and diabetes. Blood sugar levels for most patients with adult onset diabetes (type II) improve almost immediately and become completely normal within a year of surgery. Less osteoarthritis pain and improved mobility. Improved mood and self-esteem. Brett Bulseco, surgery 2/9/10, lost 200 pounds after before risks 10-20% of patient who have open bariatric surgery require follow-up operations to correct complications (abdominal hernias are the most common). Other possible post-surgical complications include infection, bleeding and death. During rapid or substantial weight loss, a person s risk of developing gallstones is increased. Gallstones can be prevented with supplemental bile salts taken for the first six months after surgery. More than 1/3 of gastric bypass patients develop gallstones, which could lead to a laparoscopic procedure known as cholecystectomy to remove the gallbladder. Nearly 30% of patients who have bariatric surgery develop nutritional deficiencies such as anemia, osteoporosis and metabolic bone disease. These deficiencies can be avoided if lifelong vitamin and mineral intake are maintained. Dumping syndrome caused by stomach contents moving too rapidly through the small intestine, resulting typically from a high intake of simple sugars and carbs. Note: It is important to know that this surgery cannot be completely reversed. The decision to have this procedure must be made in consultation with your surgeon, and a very careful consideration of the potential benefits and risks, and the lifelong consequences. 8 9

6 the normal digestive process Normally, as food moves along the digestive tract, appropriate digestive juices and enzymes arrive at the right place at the right time to digest and absorb calories and nutrients. After chewing and swallowing the food, it moves down the esophagus to the stomach, where a strong acid continues the digestive process. The stomach can hold about three pints of food at one time. When the stomach contents move through the pylorus to the duodenum (the first segment of the intestine), bile and pancreatic juice speed up digestion. Most of the calcium and iron in the foods we eat is absorbed in the duodenum. The remaining two segments (the jejunum and ileum) of the nearly 20 feet of small intestine, complete the absorption of almost all calories and nutrients. The food particles that cannot be digested in the small intestine are stored in the large intestine until eliminated. 10 Malabsorptive procedures restrictive procedures Biliopancreatic diversion and duodenal switch (ds) The DS is more effective in achieving excellent weight loss in the extremely obese, but brings with it a higher rate of true malnutrition (malnutrition is very rare for those who undergo gastric bypass). In the DS, a sleeve resection of the stomach is performed by removing about 2/3 of the stomach, maintaining continuity of the gastric lesser curve. The small intestines are arranged so that the section where the food mixes with the digestive juices is fairly short. No small intestine is defunctionalized and consistently liver problems are much less frequent. The procedure essentially eliminates stomal ulcers and dumping syndrome. Restrictive gastric procedures restrict the size of the stomach. There are several types of restrictive procedures. Vertical Banded and Silastic Ring Gastroplasties use a staple line to restrict the size of the stomach. The LAPBAND system utilizes an adjustable band that restricts the opening to the remainder of the stomach. The LAPBAND is a promising new technology that is new to the usa (approved by the FDA in june 2001). This procedure recalls the principle of doing the smallest (least invasive) procedure possible to achieve the desired result. In this method, a band is placed at the top of the stomach, creating a pouch. The opening to the rest of the digestive tract is adjustable through an epidermal port. The concept here is to create anatomy that provides a sensation of satiety after a very small meal. Weight loss for restrictive procedures is much less than that of the malabsorptive procedures and the Roux-en-Y gastric bypass. It can also be accompanied by a considerable amount of vomiting. The Vertical Sleeve Gastrectomy is regarded as a restrictive procedure where approximately 80% of the stomach is removed. The new, smaller stomach is the shape of a banana. The Sleeve Gastrectomy limits the amount of food intake, making you feel full after eating small amounts of food. After the surgeon removes most of your stomach, the remaining portions of the stomach are surgically stapled together creating a sleeve shaped stomach. This procedure does not bypass the intestines; therefore, there is no gastrointestinal malabsorption. The Ghrelin hormone is removed which significantly reduces the feeling of hunger. This procedure is not recommended for those with GERD as it may cause symptoms to worsen. 11

7 Gastric bypass may cause dumping syndrome, whereby stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and, occasionally, diarrhea after eating, as well as the inability to eat sweets without becoming so weak and sweaty that the patient must lie down until the symptoms pass. roux-en-y gastric bypass Description of the procedure (surgical technique may vary): will attach to the stomach pouch later in the operation. The standard length of the roux limb is 75 cm. Sometimes, a longer roux limb is measured in heavier patients. d ivision of the stomach the stomach is cut, using a device that simultaneously divides the tissue and places staples to seal the tissue on each side of the cut. The purpose is to create a tiny stomach pouch that is 15 to 20 ml in size. In other words, this creates a cuff of stomach on the bottom end of the esophagus. Closing of trochar sites and skin whether a larger incision for open gastric bypass or several small incisions for the laparoscopic gastric bypass have been made, the muscle defects are often closed by suture that is absorbable (stitches do not need to be cut out later). The skin incisions are then closed with suture, steri-strips or staples, depending on the surgeon s preference. Pamela Duprau, surgery 6/28/11, lost 90 pounds Ilustration Copyright 2010 Nucleus Medical Art, All rights reserved. combination procedures The Roux-en-Y gastric bypass can be regarded as a restrictive procedure; however, there is some malabsorption due to bypassing food around the duodenum and the initial part of the jejunum. The risk for pouch stretching, breakdown of the staple lines and leakage of stomach contents into the abdomen are about the same for gastric bypass as for vertical banded gastroplasty. However, because gastric bypass causes food to skip the duodenum, where most iron and calcium are absorbed, risks for nutritional deficiencies are higher. Anemia may result from malabsorption of vitamin B12 and iron in menstruating women, and decreased absorption of calcium may bring on osteoporosis and metabolic bone disease. Patients are required to take life-long nutritional supplements that usually prevent these deficiencies. Exploration of the abdomen after the abdomen is entered (with an open incision or laparoscopically using a viewing telescope and small 5 to 15 mm trocars, or tubes, through which surgical instruments are passed into the abdomen), the surgeon makes a quick check to be sure that no obvious anatomic abnormalities are present. Particular attention is given to the gallbladder and the uterus/ovaries. In open cases, the gallbladder is felt to determine if it contains gallstones, and if so, the gallbladder is removed later in operation. In laparoscopic cases, an ultrasound is done before surgery to tell if gallstones are present. A cholecystectomy may be planned if the ultrasound shows gallstones. Creation of the roux limb this part of the procedure is done by dividing the small intestine 15 to 40 cm downstream from the ligament of treitz (where the jejunum begins). The length of the roux limb is measured, which is the segment that Formation of the gastro-jejunal anastomosis (attachment of stomach gastro to the small intestinal roux limb jejunal ) this maneuver is the key part of the entire operation. This hookup must have excellent blood supply and must not have any tension remaining on it at the completion of the operation. A stapling device is used to create this connection. Other procedures, or drains cholecystectomy, tubal ligation, and placement of gastrostomy (stomach tube) or liver biopsy are done at the end of the operation as necessary and discussed with the patient. The surgeon usually places a plastic drainage tube near the gastro-jejunal anastomosis, to serve as a sentinel for a leak in this area and potentially to aid in therapy if a leak occurs. before after 12 13

8 bariatric surgery an overview of procedures expected WeigHt loss after gastric bypass Malabsorptive restrictive combination procedure pros cons Jejuno-ileal bypass Biliopancreatic Diversion and Duodenal Switch vertical Banded Gastroplasty (vbg) Silastic Ring Gastroplasty Adjustable Band Gastroplasty (LAP-BAND ) vertical Sleeve Gastrectomy Roux-en-Y Gastric Bypass Greater sustained weight loss with less dietary compliance Relatively easy operation No protein-calorie malabsorption No vitamin or mineral deficiencies due to malabsorption Sustained weight loss with limited dietary compliance Can be performed via laparoscope Increased risk of malnutrition and vitamin deficiency Constant follow-up to monitor increased risk Intermittent diarrhea and/or foul smelling stool Less weight loss maintenance More late failures due to dilation Less effective with sweet eaters Significant dietary compliance required Risk of decreased esophageal function Risk of band erosion, band slippage and silastic reaction Limited B-vitamin absorption Gradual weight gain over 15 years The gastric bypass procedure can successfully start patients on the road to recovery from morbid obesity, but surgery alone will not ensure long-term success. Surgery is a tool, something to help patients do the work. In order to get down to a healthy weight, patients must adjust their eating habits and exercise patterns. Most patients lose almost half of their excess weight in the first year and continue to lose weight after this point. There is no amount of weight loss that is guaranteed. Weight control is the personal responsibility of the gastric bypass patient. Successful habits include: Eating three small, well-balanced meals, and a maximum of one snack a day. Avoiding carbonated, caffeinated or sugary beverages and alcohol. Patients tend to gain weight back if they start eating larger portions, graze, consume high fat or junk foods or drink high-calorie beverages. Tom & Edwina Oliveira, surgery performed in 2010, together lost over 200 pounds before after A program of regular exercise is very important for promoting and maintaining weight loss. Studies have shown that patients who exercise 45 minutes at least three times per week lose an average of 18% more excess weight than patients who do not exercise regularly. Over 50% of patients achieve good to excellent weight loss results following gastric bypass surgery. Expected weight loss is 55-75% of the excess weight. More weight has been shown to be lost by patients who participated in an extensive after-care program. However, this success depends entirely on following a very restricted diet for the rest of their lives, and making major lifestyle changes. The first post-operative year is a critical time that must be dedicated to changing old behavior and forming new, lifelong habits. The success of weight loss surgery is most commonly defined by the total weight loss during the initial weight loss phase. However, in the minds of patients undergoing surgery for morbid obesity the questions are: Will this be a long-term permanent solution? What can I do to insure my lifelong success? In other words, how can I maintain at least 74% of my initial excess weight loss after a successful gastric bypass? Patients should take personal responsibility for staying in control. Patients who have a general feeling that maintaining their weight is indeed their own responsibility and that surgery was a tool they used to reach and maintain a healthy weight, succeed and do better in the long term

9 Lack of exercise, poorly balanced meals, constant grazing and snacking and drinking carbonated beverages are the basic causes of not maintaining weight loss. Additionally, regular attendance of support groups and workshops greatly increases patients compliance with the recommendations for optimal weight loss and maintenance. diet sistency of applesauce or a pudding texture. It is very important to ensure that the food you consume during this time is pureed well to prevent certain types of blockage. Step 4: In step four, the texture and the thickness of your foods should resemble a mashed or ground texture. During this step, you will add new foods to see if you are able to tolerate them. If you experience the inability to tolerate new foods, do not give it up entirely. Try it again in a few days. Each person s tolerance to different types of food varies from person to person. The only way to discover your tolerance is by trial and error. Just remember to chew your food completely and take small bites. Step 5: Congratulations, you have progressed onto solid foods! At the beginning of this step, you should still gradually increase your intake of textured foods. For example, instead of mashing down your steamed vegetables, chew your vegetables really well. In this step, you should focus more on your protein intake. The amount of protein you consume should be half the amount of a small side salad plate. The rest of the plate should consist of salads or vegetables and a small amount of carbohydrates. Remember to focus on making healthy food choices to get the maximum amount of nutrition from such a small amount of food. Also, incorporate exercise into your daily life to help with the weight loss and maintenance. nutritional expectations After gastric bypass you will need to make changes to your eating patterns. The diet after surgery progresses from a liquid diet, to a pureed diet to a soft After gastric bypass, the patients must carefully follow the recommendations outlined in the bariatric surgery guide for the rest of their life in order to maximize their weight loss success. You will need to take a protein supplement to ensure proper post-operative nutrition. In order to achieve optimal post-operative nutrition, it is essential that you take daily multivitamins and mineral supplementations for the rest of your life. Post-operative diets are separated into 5 steps. Here is an overview of the expected post-operative diet: Step 1: A clear liquid diet, started two or three days after surgery. It essentially provides hydration during the initial post-operative period. Examples of clear liquids are chicken, beef or turkey broth, water, jello and clear sport drinks. Step 2: Once you are able to tolerate clear liquids, you will begin a full liquid diet for one week. A full liquid diet usually contains more texture than a clear liquid diet. Keep in mind that these foods should all be sugar free and fat free. Some food choices include milk, yogurt, strained soups, sugar free popsicles and fudgesicles. Step 3: In step three, you will advance to a pureed diet. Step 3 usually lasts about two weeks. In this step, you will consume foods that have the condiet and then a modified regular diet. The diet progression is designed to allow your body to heal. Initially, it will help you meet your protein and liquid requirements, and later, assist you in meeting your nutritional needs. It is imperative that you follow the diet s progression and adhere to this regimen to maximize healing and minimize the risk for unnecessary complications. The size of your stomach pouch is about one ounce or one to two tablespoons. At first your capacity will be somewhat limited, so be patient. You may find that two to three teaspoons of food fill you up. This is expected. You may also find that you are able to eat more of one type of food than another. That is okay, too. Over time, your food pouch will stretch. By six months after surgery, it may stretch to eight ounces or one cup. Long term, the size of your pouch is likely to be eight to twelve ounces or 1 to 1 1/2 cups. This will limit the amount of food you can eat at one time. One of the changes that patients often comment about is the concept of wasting food. After surgery your eyes and head still work the same way as they did before. However, because of the new stomach pouch, you will be satisfied with much less. It is critical that you listen to your body s signals of fullness and not to your eyes that see food left on your plate. You may also be surprised at how the surgery changes your wants and desires for certain foods. Foods you may have previously loved, you may now find you are less interested in. It is common to see some variation from program to program related to nutrition. Just as there are many food You ll go through stages of adjustment physically and psychologically. When I realized I could never go back to the way I used to eat, I just started bawling. It was my grieving process. options, there are many options and preferences post-operatively. However, most programs agree that the primary source of nutrition should be protein. 70 to 75% of all calories consumed should be protein based (eggs, fish, meat, etc.), carbohydrates (bread, potatoes, etc.) should make up only 10 to 20%, and fats (butter, cheese, etc.) only 5 to 15% of the calories that you eat. A diet consisting of 600 to 800 calories and 75 grams of protein should be the goal for the first 6 months. Protein drinks can be helpful to fulfill your protein requirements, 16 17

10 there are many to choose from. Look for protein drinks that are low calorie, low sugar and have a good taste. Avoid foods which contain sugar. Not only will they slow down your weight loss, but they can make you sick! Sugar may cause dumping syndrome in patients who have had the gastric bypass procedure. Dumping, in short, is when sugars go directly from your stomach pouch into the small intestine causing heart palpitations, nausea, abdominal pain, and diarrhea. Symptoms may very among patients. Dumping lasts about 30 minutes to an hour and can take place 30 to 60 minutes after eating. To maintain a healthy weight and to prevent weight gain, you must develop and keep healthy eating habits. You will need to be aware of the volume of food that you can tolerate at one time and make healthy food choices to ensure maximum nutrition in minimum volume. A remarkable effect of bariatric surgery is the progressive change in attitudes towards eating. Patients begin to eat to live they no longer live to eat. As well, exercise must be part of your daily routine. general recommendations Drink fluids before the meal. Do not drink liquids with meals. Then wait 20 minutes after meals before resuming fluids to prevent pouch stretching and vomiting. Eat three tiny, protein-focused meals per day at regular times, sitting at a table. Eat slowly, savoring your food. Do not eat when feeling rushed or stressed as this may cause gastric upset. Stop eating when feeling full or if feeling any discomfort. Always cut food into small pieces and chew food very well to prevent blockage. If food should stick, try a teaspoon of Adolf s meat tenderizer in a glass of warm water, sipped slowly. Concentrate on eating protein rich foods such as fish and seafood, cheese, eggs and poultry. At mealtime, eat protein foods first before any other food. Do not snack between meals. Avoid very sweet food, candy, chocolate and high-sugar beverages to prevent the unpleasant effects of dumping syndrome. Sip liquids slowly, drinking at least 1/2 cup every hour between meals to total 8 eight-ounce cups per day to avoid dehydration. Minimize alcohol intake as it is high in calories, may cause an ulcer, and the effects may be felt much more quickly. Take a multivitamin supplement, B12 vitamin and calcium every day. Foods that MaY be difficult to tolerate Bread products Cow milk products Pasta products Fatty foods and fried foods Candy, chocolate, any sugary foods and beverages Carbonated beverages Bran cereal and other bran products Corn, whole beans and peas Dried fruits and skins of fresh fruit Coconut our bariatric surgery program team Mark Grief, M.D., FACS Bariatric Surgeon, Bariatric Program Medical Director He was trained by renowned bariatric surgeon Dr. Ninh T. Nguyen, uc Irvine, pioneer in laparoscopic Roux-en-Y Gastric Bypass. He is a board certified surgeon and has been in practice for more than 20 years. Christi Keliipio, R.N., M.S.N., FACHE Bariatric Surgery Program Director She is a former bariatric surgery patient, having lost more than 100 pounds. She has the firsthand experience to understand and guide patients to success. She received her master of science in nursing from the university of Hawai i. Maria Akagi, R.N., B.S.N. Registered Nurse She has worked in the nursing field for over 12 years and received her bachelor of science in nursing from the university of Phoenix. Sasha Goto, MBA, MAOC Program Liaison She has worked in health care for more than 5 years and received her master in business from Hawai i Pacific university. Lianne Metcalf, MS, RD, LD Clinical Dietician She received her master of science in clinical nutrition from New York university. For questions about our Bariatric Surgery Program, please contact us at (808)

11 Moanalua Road Aiea, Hawai i (808) rev. 01/14